On Jan. 27, the United States Supreme Court voted 5-4 to approve the Trump administration’s “public charge” law, also known as the health care ban. News of the decision was largely buried in the flood of dramatic impeachment headlines. The law has been fast-tracked and will go into effect Feb. 24. The aim is to refuse entry or deport those who are expected — and under the new rules, this can be a subjective, discretionary determination left up to individual immigration officers — to receive any amount of food, health or housing assistance.
The new rules will radically expand the government’s ability to define individuals with legal immigrant status as public charges, financially dependent on the government, and force deportations on that basis. Medicaid, cash assistance, food assistance and public housing are all types of public benefits that can now cause a legal immigrant to be deemed a public charge and refused entry or deported.
According to Migration Policy Institute, a nonpartisan research and analysis institute on international migration and refugee trends, the new regulations will have dire implications for the citizen children of immigrants as a result of family separations. They are also likely to affect local economies in immigrant communities as grocery stores lose revenue from SNAP, or Supplemental Nutrition Assistance Program, formerly known as food stamps. There will be negative effects as well on clinics, hospitals and publicly supported health care agencies due to reduction of health care coverage and increased reliance on emergency rooms by the uninsured.
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The Migration Policy Institute estimates that “the complex new standards for determining when an immigrant is likely to become a public charge could cause a significant share of the nearly 23 million noncitizens and U.S. citizens in immigrant families using public benefits to disenroll.”
Millions of vulnerable children may be affected as families, fearful of being deported, refuse food aid and health care benefits from SNAP and Medicaid. To make matters worse, it was the federal government that heavily encouraged enrollment in these and other federal aid programs in past years. The Migration Policy Institute estimates that “more than 4 million legal immigrants who are not yet citizens receive Medicaid. Another 9.6 million live in families in which a member (nearly always a U.S.-born child) is enrolled in Medicaid.”
And as expected, and likely intended, the Trump administration’s new rule disproportionately affects people of color.
The history of who has access to federal dollars for health care in the U.S. and who doesn’t has structural roots in the racism that has divided this country since the Civil War — roots that are playing out today in the highest court in the land. The current administration is taking steps that in many ways mirror the direction health care policy took 155 years ago, when America created the first federal system of medical care. A look back to that historic time may help make sense of how racism is foundationally entwined in our federal health care policy, and why we are the only high-income country in the world that does not provide universal health care. And why those who are white and wealthy are far more likely to remain healthy.
The years immediately following the Civil War were rife with epidemics. Slavery had technically ended, but the South was in ruins. Smallpox, yellow fever, cholera and starvation plagued the camps where freed African Americans sheltered in a post-war limbo. Mortality rates were high as mounds of dead horses, the shallow graves of soldiers, hunger, and the lack of access to the most basic health care set the stage for a massive biological crisis.
Historian Jim Downs explores this landmark period in American health care history in his book “Sick From Freedom.”
Freed blacks sent urgent pleas for help, but white leaders were profoundly ambivalent about providing that help, Downs writes. They were worried the smallpox virus and other runaway plagues could affect their own communities. They also were reluctant to offer free assistance because, they believed, it would only lead to dependence. Hard work, they argued, was the best and only way to health and vitality for the emancipated.
In response to the dire conditions, rising mortality rates and the real threat of viruses breaking into white communities, Congress finally set up a medical division of the Freedmen’s Bureau. This was the nation’s first federally funded health care program. Though half-hearted — only 120 doctors and 40 hospitals were provided for the nearly 4 million freed men, women and children — it was a significant action.
I spoke with Downs about the roots of our national health care ethos.
“Enslaved people became free in an environment plagued with disease and sickness,” Downs said. “We ignore that history, we want a triumphant notion of freedom and emancipation. But people of the time witnessed those forms of suffering and in an unprecedented move decided to call upon the federal government to help. This is all before the creation of the welfare states, the creation of any type of relief effort from the government. It is a tragic history because of the high rates of mortality, sickness and suffering, but it is a triumphant story in some way because the federal government acted in a way we have never seen it act before.”
The real motivation for providing health care had been to get formerly enslaved people healthy again for the agricultural labor force, where they were sorely missed. That motivation is still threaded into our present-day insurance practices as well.
American national health care carries an “implication about political economy,” Downs explained. This is mirrored in our present-day practice of employers providing health insurance.
“Why do employers provide health insurance?” Downs asks. “Not out of a benevolent concern. They are doing it to protect their workforce, labor, to protect their investment.”
The idea of federal aid was revolutionary, but the actual execution lacked teeth. The scant federal health care relief programs set up following the Civil War were quickly dismantled by the former slave states, which formed a voting bloc that wielded enormous political power.
“That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of ‘state’s rights,’ and, in some cases, by adding qualifications directly to federal laws with discriminatory intent,” Jeneen Interlandi wrote in an article for The 1619 Project, a New York Times Magazine initiative exploring the consequences of slavery and the contributions of black Americans.
The pattern of racial discrimination in the American health care landscape became entrenched in the years to come. From the GI Bill, which essentially excluded black service members and their families from benefits following World War II to the American Medical Association, which barred black doctors and supported restrictions on medical education for black students, federal and state policies have continued to mirror patterns of racial disparity and inequality in health care.
Fast-forward to the new health care ban for legal immigrants. Downs addresses the limbo of immigrants who, like freed African Americans, inhabit a quasi-realm where citizen rights and human rights are ill-defined.
“In today’s climate, medical rights are human rights is a weird formulation, but the question is what does human rights mean?” Downs told Street Roots. “What they are trying to do is incorporate it as an argument of citizenship and the responsibility of the state.”
Downs sees the plight of children at the border as directly analogous to the experience of blacks after the Civil War.
“An analogy of the black refugee experience that no one is talking about is the experience of children at the border dying of flu. It’s the same idea. It’s not about citizenship; it’s about occupying a political space, and therefore we don’t have to respond. Why are the children kept at the border? Because they are waiting for their hearing. They are kept in a refugee situation, and as a result, they are in conditions leading to the outbreak of disease, and they are dying. There was a case in December of children dying of the flu. They had nothing but these aluminum sheets to place over them. As the country politically works out what will happen to people at the border, having that amorphous political space has immediate health ramifications. That’s what happened after the Civil War. Black people didn’t have citizenship after the Civil War; they were not enslaved, but they were not considered citizens. They were in an amorphous political space, and that leads to medical consequences. If you are a human being living in that amorphous state, you are more susceptible to disease,” Downs said.
Street Roots spoke with Professor Evelynn Hammonds, former dean of Harvard College and professor of science and African American studies at Harvard University. She said she supported the historical arc laid out by Downs.
“The fact that we ended up with the fragmented and unequal health system that we have is directly related to institutional racism,” she said. “We’ve created a health care system, as it was built over the end of the 19th century, and an increasingly large hospital system across the U.S. throughout the 20th century that is riven with inequalities that represent the unequal distribution of health care.
“And certainly, the question of who gets to demand that state, city, federal government provides for health care for all citizens is still a contested question. What most people don’t recognize is the absolute way in which inequality and unequal distribution of health care is built into the system. That’s just structurally what people tend to miss out on as you look back over the long history.”
In light of the new Trump policy, perhaps the Statue of Liberty should be rewritten to say, “Give me your tired your poor, your huddled masses yearning to breathe free, but only if they have enough money on them to pay for the most expensive health care system in the world.”
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